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NCCN Clinical Practice Guidelines in Oncology™
Cancer-Related
Fatigue
V.1.2009
www.nccn.org
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
NCCN Cancer-Related Fatigue Panel Members
Ann M. Berger, PhD, RN, AOCN
UNMC Eppley Cancer Center at
The Nebraska Medical Center
Amy Pickar Abernethy, MD
Duke Comprehensive Cancer Center
Ashley Atkinson, RN, MSN, OCN
University of Alabama at Birmingham
Comprehensive Cancer Center
Andrea M. Barsevick, PhD, RN, AOCN
Fox Chase Cancer Center
David Cella, PhD
Robert H. Lurie Comprehensive Cancer
Center of Northwestern University
Bernadine Cimprich, PhD, RN
University of Michigan
Comprehensive Cancer Center
Charles Cleeland, PhD
The University of Texas
M. D. Anderson Cancer Center
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William S. Breitbart, MD
Memorial Sloan-Kettering Cancer Center
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Mario A. Eisenberger, MD
The Sidney Kimmel Comprehensive
Cancer Center at Johns Hopkins
Carmen P. Escalante, MD Þ
The University of Texas
M. D. Anderson Cancer Center
Pamela Hinds, PhD, RN
St. Jude Children's Research Hospital/
University of Tennessee Cancer Institute
Paul B. Jacobsen, PhD
H. Lee Moffitt Cancer Center &
Research Institute
Phyllis Kaldor, RN, MS, OCN
Arthur G. James Cancer Hospital and
Richard J. Solove Research Institute at
The Ohio State University
Jennifer A. Ligibel, MD
Dana-Farber/Brigham and Women’s
Cancer Center
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†
Matthew J. Loscalzo, MSW
City of Hope
Barbara A. Murphy, MD
Vanderbilt-Ingram Cancer Institute
Tracey O’Connor, MD
Roswell Park Cancer Institute
William F. Pirl, MD,
Massachusetts General Hospital Cancer Center
Fred Hutchinson Cancer Research Center/
Seattle Cancer Care Alliance
Hope S. Rugo, MD ‡
UCSF Helen Diller Family
Comprehensive Cancer Center
Lynne I. Wagner, PhD
Robert H. Lurie Comprehensive
Cancer Center of Northwestern University
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† £
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Eve Rodler, MD ‡
# Nursing
† Medical oncology
Psychiatry, psychology, including health behavior
Urology
£ Supportive care including palliative, pain management,
pastoral care and oncology social work
‡ Hematology/Hematology oncology
Bone marrow transplantation
Þ Internal medicine
* Writing Committee Member
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NCCN Guidelines Panel Disclosures
*
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Table of Contents
NCCN Cancer-Related Fatigue Panel Members
Summary of Guidelines Updates
Definition of Cancer-Related Fatigue (FT-1)
Standards of Care for Cancer-Related Fatigue in
Children/Adolescents and Adults (FT-2)
Screening for Cancer-Related Fatigue (FT-3)
Primary Evaluation (FT-4)
Interventions for Active Treatment (FT-5)
Interventions for Long-Term Follow-up (FT-6)
Interventions for End of Life (FT-7)
Guidelines Index
Print the Cancer-Related Fatigue Guideline
These guidelines are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to treatment.
Any clinician seeking to apply or consult these guidelines is expected to use independent medical judgment in the context of individual clinical
circumstances to determine any patient's care or treatment. The National Comprehensive Cancer Network makes no representations nor warranties
of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way. These
guidelines are copyrighted by National Comprehensive Cancer Network. All rights reserved. These guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2009.
For help using these
documents, please click here
Discussion
References
Clinical Trials:
Categories of Evidence and
Consensus:
NCCN
The
believes that the best management
for any cancer patient is in a clinical
trial. Participation in clinical trials is
especially encouraged.
To find clinical trials online at NCCN
member institutions,
All recommendations
are Category 2A unless otherwise
specified.
See
NCCN
click here:
nccn.org/clinical_trials/physician.html
NCCN Categories of Evidence
and Consensus
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Summary of major changes in the 1.2009 version of the Cancer-Related Fatigue guidelines from the 1.2008 version include:
UPDATES
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Summary of the Guidelines Updates
( )
( )
( )
FT-4
FT-5
FT-7
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Assessment of treatable contributing factors: A new bullet was added “
General Strategies for Management of Fatigue; Energy conservation: “Nap time” was changed from 45 to 20-30 minutes.
(Also for FT-6 and FT-7)
Nonpharmacologic (Also for FT-6 and FT-7):
Cognitive behavioral therapy (CBT) has a new corresponding footnote that states, “A type of psychotherapy that focuses on
recognizing and changing maladaptive thoughts and behaviors to reduce negative emotions and facilitate psychological
adjustment.”
Stress management, Relaxation and Support groups were designated as “category 1” recommendations.
“Sleep therapy” changed to “CBT for sleep”.
Optimize level of activity ”. The
constraints are listed as “Bone metastases, Immunosuppression/neutropenia, Thrombocytopenia, Anemia, Fever, and
.”
Medication side effects profile (ie, sedation)”.
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Activity enhancement; Caution:
“Fever” was changed to “Fever ”
Psychosocial interventions:
Nonpharmacologic; Activity enhancement:
“Optimize level of activity” was changed to “
The panel removed “Consider referral to rehabilitation: physical therapy, occupational therapy, physical medicine” as a
recommendation.
or active infection
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with careful consideration of the following constraints
Assessment
of safety issues (ie, risk of falls, stability)
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
DEFINITION OF CANCER-RELATED FATIGUE
Cancer-related fatigue is a distressing persistent,
subjective sense of physical, emotional and/or cognitive
tiredness or exhaustion related to cancer or cancer
treatment that is not proportional to recent activity and
interferes with usual functioning.
FT-1
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
STANDARDS OF CARE IN CHILDREN/ADOLESCENTS AND ADULT
CANCER-RELATED FATIGUE MANAGEMENT
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Fatigue is rarely an isolated symptom and most commonly occurs with other symptoms, such as pain, distress, anemia, and sleep
disturbances, in symptom clusters. Therefore, patients should be screened for multiple symptoms that may vary according to
diagnosis, treatment, and stage of disease.
Fatigue is a subjective experience that should be systematically assessed using patient self-reports and other sources of data.
Fatigue should be screened, assessed, and managed according to clinical practice guidelines.
All patients should be screened for fatigue at their initial visit, at regular intervals during and following cancer treatment, and as
clinically indicated.
Fatigue should be recognized, evaluated, monitored, documented, and treated promptly for all age groups, at all stages of disease,
prior to, during and following treatment.
Patients and families should be informed that management of fatigue is an integral part of total health care.
Health care professionals experienced in fatigue evaluation and management should be available for consultation in a timely manner.
Implementation of guidelines for fatigue management is best accomplished by interdisciplinary teams who are able to tailor
interventions to the needs of the individual patient.
Educational and training programs should be implemented to ensure that health care professionals have knowledge and skills in the
assessment and management of fatigue.
Cancer-related fatigue should be included in clinical health outcome studies.
Quality of fatigue management should be included in institutional continuous quality improvement (CQI) projects.
Medical care contracts should include reimbursement for the management of fatigue.
Disability insurance should include coverage for the continuing effects of fatigue.
Rehabilitation should begin with the cancer diagnosis.
�
FT-2
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Screen every patient for fatigue as
vital sign at regular intervalsa,b
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Age > 12 y:
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Severity: 0-10 scale
(0=No fatigue;
10=Worst fatigue you can imagine)
or
None, mild, moderate, severe
Age 7-12 y:
Severity 1-5 scale
(1=No fatigue; 5=Worst)
Age 5-6 y
Use “tired” or “not tired”
c
None to mild
(0–3)a,b
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Age 7-12 y
(1-2)
Age 5-6 y (Not tired)
Moderate (4–6)
or severe (7–10)
a,b
a,b
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Age 7-12 y
Moderate (3)
or Severe (4-5)
Age 5-6 y
Moderate or
severe (Tired)
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Education plus
general
strategies to
manage fatigued
Ongoing
reevaluation
SCREENING
a
c
Recommended screen: “How would you rate your fatigue on a scale of 0-10 over the past 7 days?”
Fatigue scale for children is simplified: Use “tired” or “not tired” as screen for young children (age < 6 or 7 y).
Butt Z, Wagner LI, Beaumont JL, et al. Use of a single-item screening tool to detect clinically significant fatigue, pain, distress, and anorexia in ambulatory
cancer practice. Journal of Pain and Symptom Management 2008; 35(1): 20-30.
b
dSee “Patient/Family Education and Counseling” and “General Strategies for Management of Fatigue” based on clinical status: ,
, .
Active Treatment (FT-5)
Long Term Follow-up (FT-6) End of Life (FT-7)
See Primary
Evaluation (FT-4)
FT-3
Education plus
general
strategies to
manage fatigued
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
Focused history
Depression
Anxiety
Medication side effects profile (ie, sedation)
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Disease status and treatment
Rule out recurrence or progression
Current medications/medication changes
Prescription/OTCs and supplements
Review of systems
In-depth fatigue history
Onset, pattern, duration
Change over time
Associated or alleviating factors
Interference with function
Assessment of treatable contributing factors:
Pain
Emotional distress
Anemia
Sleep disturbance (eg, obstructive sleep apnea,
restless leg syndrome, narcolepsy, insomnia)
Nutrition Assessment
Weight/caloric intake changes
Fluid electrolyte imbalance: sodium, potassium,
calcium, magnesium
Activity level
Decreased activity
Decreased physical fitness
Comorbidities
Infection
Cardiac dysfunction
Pulmonary dysfunction
Renal dysfunction
Hepatic dysfunction
Neurologic dysfunction
Endocrine dysfunction (hypothyroidism,
hypogonadism, adrenal insufficiency)
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Pain
See NCCN Cancer
Pain Guideline
Anemia
See NCCN Cancer-and-
Chemotherapy Induced
Anemia Guideline
Sleep
disturbance
Emotional distress
See NCCN Distress
Management Guideline
PRIMARY SCORE:
Age > 12 y (4-10), Age 7-12 y (3-5), or Age 5-6 y (Tired)
EVALUATION FATIGUE MODERATE OR SEVERE
Treatable
contributing
factors
No other factors
Nutrition
Evaluation/Medical
Interventions
Activity level
Comorbidities
Active
treatment
Follow-up,
no active
treatment
(except
hormonal
therapy)
End of life
See
Interventions
(FT-5)
See
Interventions
(FT-6)
See
Interventions
(FT-7)
PATIENT CLINICAL STATUS
FT-4
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
INTERVENTIONS FOR PATIENTS ON ACTIVE TREATMENTe
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Consider
psychostimulants
(methylphenidate or
modafanil) after
ruling out other
causes of fatigue
Treat for anemia as
indicated
Consider sleep
medication
i
(See NCCN
Guidelines)
Cancer-and-
Chemotherapy
Induced Anemia
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Trials: NCCN believes that the best management of any cancer patient is in a clinical trial. Participation in clinical trials is especially encouraged.
�
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Activity enhancement (category 1)
Maintain optimal level of activity
Consider initiation of exercise program
Consider referral to rehabilitation:
physical therapy, occupational therapy
& physical medicine
Caution:
Anemia
Psychosocial interventions
Cognitive behavioral therapy (CBT)
(category 1)
Stress management (category 1)
Relaxation
Support groups (category 1)
Attention-restoring therapy
(eg, nature)
Nutrition consultation
CBT for sleep
Sleep hygiene
Stimulus control
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Bone metastases
Immunosuppression/neutropenia
Thrombocytopenia
Fever or active infection
Limitations secondary to metastases
or other illnesses
Sleep restriction
g
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(See MS-9)
See MS-10( )
eSee Discussion for information on differences between Active treatment,
Long term follow-up, and End-of-life treatment.
fInterventions should be culturally specific and tailored to the needs of patients and
families because not all patients may be able to integrate these options due to
variances in individual circumstances and resources. (Sahler OJZ, Varni JW,
Fairclough DL, et al. Problem-Solving Skills Training for Mothers of Children with
Newly Diagnosed Cancer: A Randomized Trial. Journal of Developmental &
Behavioral Pediatrics. 23(2):77-86, April 2002)
( )See MS-1
Information about
known pattern of
fatigue during and
following treatment
Reassurance that
treatment-related
fatigue is not
necessarily an
indicator of disease
progression
�
FT-5
Patient/Family Education
and Counseling
General Strategies for
Management of Fatigue
Nonpharmacologicf Pharmacologic
SPECIFIC INTERVENTIONS
�
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Self-monitoring of fatigue
levels
Energy conservation
Set priorities
Pace
Delegate
Schedule activities at
times of peak energy
Labor-saving devices
Postpone nonessential
activities
Limit naps to 20-30
minutes or less so as to
not interfere with night-
time sleep quality
Structured daily routine
Attend to one activity at
a time
Use distraction
(eg, games, music,
reading, socializing)
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Repeat
evaluation
See (FT-4)
g
h
i
Concern is with environment. Limit activity to environments where risk of infection is low.
A type of psychotherapy that focuses on recognizing and changing maladaptive thoughts
and behaviors to reduce negative emotions and facilitate psychological adjustment.
Pharmacological interventions remain investigational, but have been reported to improve
symptoms of fatigue in some patients. There is more evidence for methylphenidate and
less for modafinil. These agents should be used cautiously and should not be used until
treatment and disease specific morbidities have been characterized or excluded.
Optimal dosing and schedule have not been established for use of psychostimulants in
cancer patients.
Version 1.2009, 01/15/09 © 2009 National Comprehensive Cancer Network, Inc. All rights reserved. These guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
Cancer-Related Fatigue
Guidelines Index
Cancer-Related Fatigue TOC
Discussion, References
Practice Guidelines
in Oncology – v.1.2009NCCN
®
�
�
Energy conservation
Set priorities
Pace
Delegate
Schedule activities at
times of peak energy
Labor-saving devices
Postpone nonessential
activities
Limit naps to 20-30
minutes or less so as to
not interfere with night-
time sleep quality
Structured daily routine
Attend to one activity at
a time
Use distraction
(eg, games, music,
reading, socializing)
�
�
�
�
�
�
�
�
�
�Activity enhancement
(category 1)
Maintain optimal level of activity
Consider initiation of exercise
program
Consider referral to
rehabilitation: physical therapy,
occupational therapy, physical
medicine
Caution:
Psychosocial interventions
(category 1)
CBT (category 1)
Stress management (category 1)
Relaxation
Support groups (category 1)
Attention-restoring therapy
(eg, nature)
Nutrition consultation
CBT for sleep
Sleep restriction
Sleep hygiene
Stimulus control
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�
�
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Late effects of treatment
(eg, cardiomyopathy)
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�
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h
(
( )
See MS-9)
See MS-10
Information about
known pattern of
fatigue during and
following treatment
Self-monitoring of
fatigue levels
�
INTERVENTIONS FOR PATIENTS ON LONG-TERM FOLLOW-UPe
Note: All recommendations are category 2A unless otherwise indicated.
Clinical Tr
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